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Nurses Improving Mental Health Care

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By Debra Wood, RN, contributor

May 13, 2011 - Nurses are on the front lines—fighting the stigma of mental illness, improving access to services and changing the way psychiatric care is delivered—during Mental Health Month, observed each May, and throughout the year.

“Nurses are the ultimate bridge between the psych/social dimensions and medical dimensions [of care],” said Michael J. Rice, Ph.D., APRN-NP, a professor of psychiatric nursing at the University of Nebraska Medical Center College of Nursing in Omaha and associate director of the Behavioral Health Education Center of Nebraska. Rice explained that mental health problems result from an intense combination of genetics, biochemistry, environment and vulnerability.

“It’s a matter of helping people cope regardless of the etiology of the illness and having people lead the most successful lives they can lead,” said Gail Stern, MSN, administrator of the department of psychiatry at Lehigh Valley Health Network in Allentown, Penn..

“Psych nurses are educated to view the patient holistically; that is to assess and provide appropriate interventions for mental, physical and emotional needs,” added Rebecca Horn, MSN, RN-BC, an inpatient psychiatry unit nurse at Texas Health Presbyterian Hospital Dallas. She and fellow nurses create a safe milieu for severely depressed and psychotic patients.

Yet it not just psychiatric nurses who work with mentally ill patients. Nurses in all settings are caring for patients with depression, anxiety and other conditions.

“Mental health concerns have an enormous impact on people’s general health,” said Beth Phoenix, RN, Ph.D., CNS, assistant clinical professor at the University of California, San Francisco School of Nursing. She encourages nurses to provide accurate information and help patients with mental illnesses obtain prompt behavioral health treatment to reduce disabilities. “There needs to be an attitude of acceptance and willingness to talk about it.”

Debbie Thomas, EdD, ARNP, PMHCNS-BC, said psychiatric NPs can prescribe medications to help shore patients up, so they can participate in therapy.

Nurses helping overcome the stigma of mental health

“The biggest issues we deal with in mental health are stigma and access to care, and that’s where advanced care psych nurses come into play,” said Debbie Thomas, EdD, ARNP, PMHCNS-BC, associate professor and coordinator of graduate advanced practice psychiatric-mental health nursing studies at the University of Louisville School of Nursing in Kentucky. “They can do a lot to promote mental health and mental wellness.”

Thomas said psychiatric-mental health nurses can help people understand they are not alone in suffering from anxiety or depression and intervene.

Stern encouraged nurses to view psychiatric patients as doing the best they can and assist people in those efforts.

“It’s being open to the person’s perspective, understanding their pain and being comfortable with it,” said Stern, recommending that nurses need to become more comfortable discussing patients’ feelings and emotions and suggesting ways to manage them.

The American Psychiatric Nurses Association (APNA) received a federal grant to support its Recovery to Practice Initiative, seeking to promote a recovery-oriented approach to mental health care by developing and disseminating training curricula for different settings about translating the concept of mental health recovery into practice. The program also will provide a resource center for mental-health professionals.

“The recovery model instills hope that people can live healthy, productive lives with treatment,” said Carole Farley-Toombs, MS, RN, NEA, BC, director of clinical operations for acute psychiatric services at Strong Behavioral Health in Rochester, N.Y., and president of APNA.

Marlene Nadler-Moodie, MSN, APRN, PMHCNS-BC, a nurse consultant and president-elect of APNA, discussed how beneficial the A-Visions program at Scripps Mercy Hospital in San Diego, where she works, has been to recovering patients. The hospital initially places former patients in a volunteer position and provides training and mental-health support. After three months, the hospital hires those who have done well.

“It’s very rewarding to see patients who were incredibly sick, now working in the hospital,” Nadler-Moodie said. “Mental illness is not hopeless. Recovery is possible, and it happens. Patients can function beyond survival. They grow and live full lives, and nurses help make that happen.”

Nursing opportunities and improving access

For nurses with an inclination to care for the mentally ill, many opportunities present themselves, and according to a 2010 survey sponsored by Janssen, a division of Ortho-McNeil-Janssen Pharmaceuticals, more than three-fourths of psychiatric nurses feel they are very responsible for educating patients about aspects of mental health and more than two-thirds feel a great deal of responsibility in the care of psychological problems and managing patients’ overall well-being.

“Nurses feel they are the most involved,” said Dorothy Hill, RN-C, a consultant with Janssen. “They are on the front line and are involved with the patient on a day-to-day basis.”

Registered nurses and advanced practice nurses work with children and adults in inpatient and outpatient mental health and substance abuse-treatment settings.

“There are a lot of opportunities for nurses in direct psychiatric care and seeing patients in the general care setting,” said Nadler-Moodie, adding that primary care practices are beginning to include psychiatric services at the same location.

Advanced practice nurses may establish private practices in many states without a collaborative agreement with a physician, improving access to mental health services.

“Patient outcomes are equal to or better than that of physicians, and the reason indicated in the literature is because people say nurse practitioners listen more,” said Thomas, who has maintained a private practice since 1992. “If someone feels heard, they are more likely to be adherent to whatever regimen you prescribe.”

Stern agreed and said she has found people will open up and share their thoughts and insights if the nurse asks the right questions and then listens.

With a holistic approach to patient care, nurses have stepped forward to improve mental health care.

Kathy Regan, RN, MHA, NE, BC, nurse manager of the Child Assessment Unit at Cambridge Health Alliance, a Harvard-affiliated public health care system located outside Boston, adopted an “Open Arms” approach to managing children’s difficult behaviors rather than using restraints or seclusion.

“By doing thorough assessments and observations we get a better understanding about why the child has explosions,” said Regan, explaining that then the nurses can discuss collaborative solutions with parents. “You may work a little harder, but the rewards are much more satisfying.”

Nurses at Texas Health Dallas have begun teaching staff a new approach to helping patients with eating disorders. They are implementing dialectical behavior therapy, which includes distress tolerance and core mindfulness interventions.

Rice serves as project director of the Primary Integrated Psychiatric Nursing project in Nebraska, a grant funded program to train nurses throughout the state as psychiatric nurse practitioners, using secure video conferencing that connects them with psychiatrists with whom they can work in collaborative practice.

“The goal is to keep 70 percent of them in rural areas,” Rice said. “We found if you teach them in the rural communities, they will stay there.”